Having recently taken effect on July 1, 2021, The Joint Commission (TJC) has officially made Business Occupancies, typically Ambulatory Care facilities or MOBs, surveyable. Life Safety (LS) requirements will now include Business Occupancies during the process of accreditation. These new regulations are going to impact Healthcare Systems a great deal as most organizations have a considerable amount of Business Occupancies associated with their Centers for Medicare & Medicaid Services (CMS) Certification Number.

Although the Environment of Care (EOC) Chapter has always included requirements that impact Business Occupancies, the section never specifically referenced LS requirements. The potential for surveys in Business Occupancies was always there but the probability of those physical environments being surveyed has greatly increased. Not knowing which of the hospital system’s many Business Occupancies is going to be surveyed is the real challenge.

In accordance with NFPA 101 Section 3.3.134.3, a Business Occupancy is “used for account and record keeping or the transaction of business other than mercantile”. In reference to healthcare, the translation refers to space where there are no overnight stays and where three (3) or fewer individuals are tended to and are determined incapable of self-preservation at any given time in light of their treatment. Furthermore, if a person is incapable of self-preservation this means they do not have the ability to leave the building themselves with or without the help of mechanical assistance such as a wheelchair.

To summarize, there are five (5) new standards and twenty-nine (29) new elements of performance that address fire safety and means of egress during fire emergencies:

  • Standard LS.05.01.10 – Building & fire protection elements
  • Standard LS.05.01.20 – Means of egress
  • Standard LS.05.01.30 – Building elements
  • Standard LS.05.01.34 – Fire alarm systems
  • Standard LS.05.01.35 – Fire extinguishing equipment & systems

The best recommendation that TJC is offering to tackle these new requirements is to create a Building Maintenance Program (BMP) that should be organized and planned to obtain successful compliance within Business Occupancies. The following elements need to be taken into consideration when addressing these new standards:

  • 18″ or more of open space is kept below the sprinkler to the top of storage
  • 75′ or less is the travel distance from any point to the nearest fire extinguisher
  • Alcohol-based hand rubs (ABHR) are reserved and organized in accordance with NFPA 101-2012
  • A one (1) hour fire resistance-rated barrier or a smoke resistive barrier and automatic sprinklers are needed for protection between hazardous areas and anywhere else
    • Self-closing or automatic closing doors are needed with latching hardware
  • Assessment of fire barriers, fire-rated smoke barriers and fire-rated smoke partitions
  • Corridors or passageways must have a minimum 44″ of clear width in occupancies that serve fifty (50) or more people
  • Dead-end corridors in existing facilities cannot be longer than 50′ and in new facilities the dead-end corridors cannot be longer than 20′ unless they are fully sprinklered
  • Decorations, coverings and other items should not be stuck to a door with a fire rating of forty-five (45) minutes or more
    • Informational signs are the exception as long as they are applied with an approved adhesive
  • Emergency powered lighting for new construction is provided if the building is:
    • Three (3) or more stories high
    • Filled with one hundred (100) or more occupants in the stories above or below the level of exit discharge
    • Filled with one thousand (1,000) or more total occupants
  • Emergency powered lighting for new construction is provided if the building is:
    • Three (3) or more stories high
    • Filled with fifty (50) or more occupants in the stories above or below the level of exit discharge
    • Filled with three hundred (300) or more total occupants
  • Exits and exit access corridors for interior wall and ceiling finishes must be Class A or B
    • Everywhere else should be Class A, B or C
  • Exit’s travel distance must not be more than 200′ and can increase to 300′ if the space is fully sprinklered
  • Fire alarm systems are needed for existing construction if the building is:
    • Three (3) or more stories high
    • Filled with one hundred (100) or more occupants above or below exit discharge level
    • Filled with one thousand (1,000) or more occupants
  • Fire alarm systems are needed for new construction if the building is:
    • Three (3) or more stories high
    • Filled with fifty (50) or more occupants above or below exit discharge level
    • Filled with three hundred (300) or more occupants
  • If not greater than one (1) level below the street floor, interior open stairways and ramps are able to be part of the egress system
  • Means of egress while occupied must be consistently illuminated by Emergency Powered Lighting
  • Pipes, cables, conduits, bus ducts, wire, air ducts or pneumatic tubes passing through the floor or walls must be protected with approved fire-rated material
    • Polyurethane expanding foam that has not been approved is not an acceptable fire-rated material here
  • Protection of vertical openings
    • Opening below street level that has storage or communicates with another occupancy
    • New construction – enclosure services four (4) or more floors – 2 hour fire rating
    • New construction – enclosure services three (3) or less floors – 1 hour fire rating
    • Existing construction – ½ hour fire rating  
  • Separation occurs between buildings and parking structures by a two (2) hour or more fire barrier
  • Sprinklers must be not damaged; free of corrosion, paint and foreign materials; and have required escutcheon plates installed
  • Unless noted compliant, latches or locks that open with a tool or key are not permitted on doors in a means of egress
    • Compliant latch/lock systems include a delayed egress-locking system or an access-controlled egress door assembly

*Note: TJC’s recommendation to create BMP is not mandatory but just a suggestion and one that JPT supports.

If you would like to download the list of elements taken into consideration when addressing TJC’s new LS Standards for Business Occupancies, check out JPT’s document below:

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